A client is transferred to the medical-surgical unit following a diagnostic lumbar puncture to evaluate a sudden onset of severe headaches and nuchal rigidity. Which nursing interventions are essential to incorporate into the client's immediate care plan to mitigate the risk of post-procedure complications? Select all that apply.
- Maintain the client in a flat, supine position for the duration prescribed by the healthcare provider.Answer
- Encourage liberal oral fluid intake unless clinically contraindicated.Answer
- Assess the lower back insertion site dressing frequently for clear moisture or active bleeding.Answer
- DPlace the client in an upright sitting or semi-Fowler's position immediately to promote optimal lung expansion.
- EDelegate the initial post-procedure evaluation of lower extremity sensory and motor function to the unlicensed assistive personnel (UAP).
- FPrioritize administering a prescribed prophylactic analgesic over completing a baseline neurological and airway assessment.
Answer
The essential nursing interventions include maintaining a flat, supine position, encouraging liberal fluid intake, and closely monitoring the insertion site dressing for moisture or bleeding.
Following a lumbar puncture, the primary goals are to prevent cerebrospinal fluid (CSF) leakage and monitor for neurological complications. Maintaining a flat position and increasing hydration help maintain CSF volume and intracranial pressure, preventing spinal headaches. Direct observation of the puncture site allows for early detection of complications such as hematomas or ongoing CSF leaks.
Step-by-Step Solution
Key Concept
Post-Lumbar Puncture Risk Reduction and Complication Management